INFORMED CONSENT FOR TREATMENT WITH HYALURONIDASE

In the doctor-patient relationship, it is necessary and ethically correct for the latter to assume a conscious and participatory role in relation to the treatment and diagnostic tests to which the patient voluntarily intends to undergo, as also provided for in Articles 3, 34, 35, 36, and 37 of the Code of Medical Ethics. For this reason, the patient is informed in a comprehensible manner about his or her problem and/or pathology, the possible treatments are explained, and the rationale for choosing the one(s) deemed most suitable to achieve the expected clinical outcome is provided. It is therefore important that the explanations summarized in the information leaflet on carboxytherapy treatment—extensively illustrated by the doctor—have been well understood and deemed comprehensive by the patient.


To this end, the undersigned

I CONFIRM
that my doctor has provided sufficient information to help me understand the use of the carboxytherapy treatment described above, allowing me to make a free, responsible, and informed decision. He has given me the opportunity to ask any questions I deemed useful regarding the proposed treatment, and I am satisfied with the answers I received. He has given me time to consider the treatment described above. He has informed me that he will be available to me if I have any further questions and/or clarifications I deem necessary. The doctor did not force me to undergo this treatment, and I understand that I can change my mind at any time before starting the treatment.


I CONFIRM
that the doctor—in order to allow me to make a voluntary, free, and informed decision regarding carboxytherapy treatment—has provided me with extensive, complete, and comprehensive explanations of the information contained in this information sheet, with particular reference to the therapeutic protocol, my clinical situation and related diagnosis, therapeutic options, benefits, limitations, alternatives, indications, contraindications, possible side effects, the indications and procedures I will need to follow pre- and post-treatment to achieve the desired result, complications and outcomes, as well as the frequency and repetitiveness of the treatment itself. I am aware of the importance of having answered accurately and sincerely the questions asked by the doctor about my health status, any allergies, sensitivities, excipients, medications taken recently or currently, as well as previous therapies or medical or other treatments performed in the areas being treated, as well as having answered the doctor's questions accurately and honestly.


I DECLARE
that I have no other questions or concerns regarding the treatment and that I am satisfied with the answers I received from the doctor, who has provided me with a copy of this information sheet along with the informed consent form (seven pages in total). I also declare that I will contact the doctor promptly if one or more contraindications and/or side effects occur following the treatment.


ALTERNATIVE PROCEDURES AND PURPOSE OF TREATMENT
I have been informed of the alternative procedures, their advantages and disadvantages, risks and benefits, and I am aware that I have fully understood them and will opt for this treatment. I understand that the quality of the results cannot be assessed a priori, and that I have not been given precise guarantees regarding the results I will achieve with this treatment, as individual response and conditions may be essential in determining the outcome of the treatment.

Having read the above, believing I have correctly understood it and obtained the requested clarifications, and having had the opportunity to evaluate the risks and benefits of the treatment covered by the information received,
I CONSENT to the doctor to perform the medical treatment procedure with INDICATION for the following indication/purpose:

The areas to be treated, agreed between me and the doctor, are the following:

Notes on treatment, specific risks or complications, related to the patient's subjective condition:

GENERAL INFORMATION ON THE PROCESSING OF PERSONAL DATA
Pursuant to Articles 13 and 14 of EU Regulation No. 2016/679 (the "Regulation") and the provisions of Legislative Decree No. 101/18 (the "Legislative Decree") concerning the protection of natural persons with regard to the processing of personal data, I hereby inform you that the personal data you provide and acquired by Clinica Milano – Skin Lab ® will be processed in compliance with the provisions of the aforementioned Regulation and Legislative Decree. Furthermore, the following is specified:

1. Purpose of processing

The processing of your personal data is solely for the proper performance of aesthetic medicine, prevention, diagnosis, treatment, rehabilitation, or other pharmaceutical and/or specialist services requested by you.

2. Methods of Processing Personal Data

Processing is carried out through operations performed on paper or with the aid of IT tools, or via apps and cloud platforms, and consists of the collection, recording, organization, storage, consultation, processing, modification, selection, extraction, comparison, use, interconnection, blocking, communication, deletion, and destruction of such data. Sometimes, it may be necessary to send data electronically via email, which will be encrypted and password-protected. Processing is carried out by the data controller and by persons expressly authorized by the data controller.

3. Provision of Data and Refusal

The provision of general, sensitive, genetic, and health-related personal data is necessary for the performance of the activities required for prevention, diagnosis, treatment, rehabilitation, or other pharmaceutical and/or specialist services requested by you. Your refusal to provide personal data will make it impossible to perform these activities.

4. Data Disclosure

The personal data collected will not be disclosed. The data will not be shared with third parties, except when necessary and/or required by law and/or for tax compliance. The data will be disclosed only to healthcare personnel at the facility where Clinica Milano – Skin Lab® operates and, where necessary, to physicians, analysis laboratories, medical specialists, hospitals, and consultants—lawyers and/or accountants—used by Clinica Milano – Skin Lab®.


5. Data Retention

Your personal data will be retained for the time strictly necessary for medical care and, in any case, for no longer than ten years. Even when computers are used, appropriate protection measures are adopted to ensure the correct storage and use of data, including by medical practice staff, in compliance with professional secrecy. Professionals and facilities that may have access to such data as a result of the healthcare services provided by Clinica Milano – Skin Lab ® are also required to observe these safeguards.

6. Data Controller

The data controller is Clinica Milano – Skin Lab ®, Via Cerva, 22 – 20122 Milan – SEM s.r.l. | VAT No. 11055590969

7. Rights of the Data Subject

The data subject has the right:

• to request from the data controller access to, rectification or erasure of, or restriction of processing of, personal data, or to object to processing, as well as the right to data portability;
• to receive, in a structured, commonly used, and machine-readable format, the personal data concerning him or her, which he or she has provided to a data controller, and has the right to transmit those data to another data controller without hindrance from the data controller to which the personal data have been provided;
• to withdraw consent at any time, without affecting the lawfulness of processing based on consent before its withdrawal;
• to lodge a complaint with the Italian Data Protection Authority.

The aforementioned rights may be exercised by written communication sent via certified email to semsrl1@pec.it or by registered mail with return receipt to Via Cerva, 22 – 20122 Milan.

With reference to the images (photos and/or videos) taken and/or filmed by Clinica Milano – Skin Lab ®, which are essential for developing your treatment plan and managing diagnoses and future assessments, you authorize, free of charge and without time limits, also pursuant to Article 10 of the Italian Civil Code and Articles 96 and 97 of Law No. 633 of April 22, 1941 (Copyright Law), the storage in your medical records in paper format or with the aid of IT tools or via apps and platforms that use the Cloud, and the possible publication and/or dissemination of your images in any form on the Clinica Milano – Skin Lab ® website or on its social media profiles such as Instagram or Facebook. I also authorize the storage of these photos and videos in the electronic archives of Clinica Milano – Skin Lab®, confirming that the purpose of such publications is purely for informational and educational purposes regarding the professional activities carried out by Clinica Milano – Skin Lab®. This authorization may be revoked at any time by written notice sent by registered mail or certified email.

The undersigned declares that he or she has read the above information, accepts all of its provisions, and consents to the processing of his or her personal data for the purposes, terms, and conditions set forth above.

IN FAITH



Clinica Milano – Skin Lab ®

I agree to be legally bound by this consent
and the Electronic Signature Terms of Use.